Controversy has surrounded many major breakthroughs in medicine; the field of Ophthalmology has not been immune. The anatomical origins of cataract have historically been matters of debate, despite the ancient Indian writings of Susruta (800-600 BC) that described cataract as a disorder of the lens.[1] Susruta may have been the first physician to perform surgery for cataracts, using a technique known as couching. Couching is a procedure in which an instrument is used to dislocate the cloudy lens from its anatomical position into the vitreous cavity.

Despite evidence to the contrary that couching was ineffective, it was widely used, even after Jacques Daviel proposed what he believed to be a superior technique: removal of the cloudy lens. Daviel honed his technique on cadavers as well as living slaves and prisoners. He subsequently learned that other French surgeons had successfully extracted lenses following removal of lens material in the anterior chamber of the eye, resulting in vision improvement after failed couching procedures. In 1752, Daviel presented evidence garnered from 206 consecutive patients in which he removed cataracts via corneal incisions: nearly 88% had “favorable results.” Daviel's peers were critical of his technique, and thus, the French Academy of Surgery initiated a surgical trial of 19 elderly soldiers with advanced cataracts; the soldiers were selected for participation for the trial by a hospital administrator. Three surgeons participated (1 of whom used the couching technique). Half of the couchings were deemed successful and 9 of 13 surgical lens removal outcomes were “good” or the “same as before the lens extraction.” Interestingly, even this demonstration of efficacy did not dispel the notion that couching was preferable.[2]

In 1752, de la Faye performed corneal section in France using a novel single knife; however, Sharp was the first to employ the technique the following year in London, proclaiming that it shortened the surgical time and lessened pain. This slight modification of the technique enhanced Sharp's reputation, particularly in the English-speaking world, consequently diminishing Daviel's contribution. Similar controversy ensued when Charles Kelman introduced a new lens extraction technique, known as phacoemulsification in 1967. In 1973, Kelman reported drastically reduced surgical time in 500 cases treated using the procedure; however, few ophthalmologists adopted phacoemulsification. New equipment necessitated a steep learning curve, resulting in an increased rate of complications. Decades later, in 1994, over 25,000 records from a major survey were reviewed. It was incorrectly concluded that phacoemulsification was as but not more effective than intracapsular surgery. This technique is now the standard for cataract surgery, coupled with implantation of an intraocular lens.[2]

Regrettably, the earlier advances in medicine (pioneered by Susruta, Hippocrates, and others) were gradually lost to the Western world in the first millennium AD, and the status of a surgeon in Europe was degraded to that of a tradesman. In fact, it was the town barber who performed the surgery of the day.[3] Although the contributions of Susruta and Daviel are recognized today among modern ophthalmologists, they were not appreciated during their time. Western medicine did not accept the anatomical findings of Susruta, French surgeons did not readily accept that lens removal was superior, and American ophthalmologists resisted the technological advancement (phacoemulsification of cataract) that is now the gold standard of modern cataract surgery. One could blame a lack of knowledge of ancient India and language barriers for the former; however, the latter are examples of resistance to novel treatments that were shown to benefit patient outcomes.

Dr. Vadrevu K. Raju was born in Rajahmundry, AP, India. He is MBBS from Andhra University in India, Fellow of the Royal College of Surgeons, Fellow of the American College of Surgeons, Clinical Professor of Ophthalmology at West Virginia University, Director of the International Ocular Surface Society, Director of the Ocular Surface Research and Education Foundation, , Chairman of Goutami Eye Institute in Rajahmundry and is the President and Founder of the Eye Foundation of America. The partial list of his awards and honors include: AMA Foundation Nathan Davis Excellence in Medicine International Award, Four Time Awardee by The American Academy of Ophthalmology, Martin Luther King Jr Achievement Award from WVU, Distinguished Community Service Award from AAPI (American Association of Physicians from India) and most recently the Lifetime Achievement Award from WV state medical association.